Oral Pregabalin analgesia after arthroscopic rotator Cuff repair as good as regional block

Tel Aviv, Israel: E. FARLADANSKY et al conducted a randomized trial to compare the analgesic effects of pregabalin to those of single-shot interscalene brachial plexus block (ISBPB) in adults having arthroscopic rotator cuff (RC) repair. They found that perioperative use of pregabalin provided analgesia comparable to that of interscalene brachial plexus block (ISBPB) for 10 days after surgery.

The study has been published in the journal Arthroscopy.

Arthroscopic rotator cuff (RC) repair is often associated with severe postoperative pain and discomfort. Many analgesic protocols have been proposed for pain relief after RC repair, and controversy remains regarding the optimal postoperative analgesic protocol. Despite significant advancement in analgesic techniques, 50% to 70% of patients who undergo surgical procedures still experience moderate to severe postoperative pain. Opioids are commonly used for postoperative pain reduction; however, their use is associated with numerous adverse effects and should be limited. Regional nerve blockade, including ISBPB, is occasionally associated with temporary neurological symptoms during the first postoperative week (4% to 16%), is technically demanding, and might be time consuming (up to 40 minutes before induction of anaesthesia). Pregabalin (Lyrica) is an anticonvulsant with membrane-stabilizing and antinociceptive effects commonly used for neuropathic pain relief and anxiety disorder. Also used for its analgesic effect on acute postoperative pain.

Method of study- In this randomized trial, 79 adults having arthroscopic RC repair were randomized to receive perioperative oral pregabalin (Lyrica, twice daily starting the evening before surgery, for a total of 4 doses) or single-shot ISBPB (20 ml of bupivacaine 0.25%). Intra- and postoperative management was standardized. The primary outcome was median self-reported pain score (on a visual analog scale of 0 to 100) at rest during the initial 10 postoperative days. Other outcomes included pain during activity, postoperative opioid consumption, opioid-related adverse effects, quality of recovery, and pain satisfaction score.

Results:

• Of 71 eligible patients, 59 were analysed, of whom 29 received pregabalin and 30 received ISBPB.

• Groups were similar regarding demographic, baseline, and intraoperative variables. Median pain score at rest over the 10 postoperative days was 51 (interquartile range 26, 76) in the pregabalin group and 52 (22, 74) in the ISBPB group (difference 0.5 points; 95% confidence interval [CI] -3.2 to 6.3; P =.53).

• There was no difference in the primary outcome of average pain score over the initial 10 postoperative days: mean +/- SD VAS score 51.5 +/-29 in the pregabalin group versus 50.0 +/- 31 in the ISBPB group; difference

(95% confidence interval [CI]) 1.5 points (-3.2 to 6.3); P=.53)

• Similar trends were found regarding pain during shoulder movement, with VAS score over the 10-day period 63.5 +/- 29 in the pregabalin group versus 60.9 +/- 32 in the ISBPB group (P = .3)

• Opioid consumption during the initial 10 postoperative days was also similar (difference in median 90 mg of morphine equivalents; 95% CI -32 to 177.5; P= .12).

• There were no differences between the groups in either ORSDS (opiod related symptom distress scale) score or overall patient satisfaction with pain management. They found no study-related harms or adverse events.

The authors mentioned that future studies are still required to verify their results in larger cohorts, using different analgesics (such as bupivacaine liposome injection (Exparel), recently approved for a single-injection ISBPB), and different clinical setups(ambulatory patients, other nonopioids, etc.) 

Further reading:

Perioperative Oral Pregabalin Results in Postoperative Pain Scores Equivalent to Those of Interscalene Brachial Plexus Block after Arthroscopic Rotator Cuff Repair: A Randomized Clinical Trial

Elena Farladansky, M.D., Ph.D., Shoshana Hazan, R.N, M.A., Eran Maman, M.D., Alon Menashe Reuveni, M.D., Anat Cattan, Ms.C., Idit Matot, M.D., and Barak Cohen, M.D.

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 38, No 1 (January), 2022: pp 31-37

https://doi.org/10.1016/j.arthro.2021.05.022